16 November 2007
Eradicating hospital infections is not just about intensive cleaning. The ways in which demanding targets have been reached might be a cause of the problem and amount to false economies. Noel Plumridge reports
First the good news. The NHS in England is back in financial balance. Public Finance readers who are missing their diet of 'NHS trust in financial crisis' stories might need to wait until next summer, when the combined impact of sharply reduced financial growth and optimistic Department of Health targets for efficiency gains in 2008/09 might yet mean that normal service is resumed. For the present, however, the impressive turnaround that took the NHS from a £547m deficit in 2005/06 to a £510m surplus in 2006/07 – 'unprecedented', according to Department of Health finance and investment director Richard Douglas – continues.
More good news. Immense improvements in patient access over recent years have made waits for hospital treatment of 12 months and then nine months a distant memory, and along the way have seriously dented the private earnings of surgeons. Not content with this, the NHS now appears likely to achieve its latest access target: a maximum wait of 18 weeks. The bottleneck of diagnostics has been expanded by the introduction of new private sector capacity, and lubricated by much managerial sweat and tears.
But now for some very bad news. Ninety deaths in a single Kent hospital trust. A Healthcare Commission report published last month suggests that between April 2004 and September 2006 no fewer than 90 patients died 'definitely or probably' as a result of Clostridium difficile infections. Health Secretary Alan Johnson maintains that Maidstone and Tunbridge Wells NHS Trust is far from typical of the NHS. Yet, according to the Healthcare Commission, more than a quarter of all acute hospital trusts are not meeting modern infection control criteria. The commission's annual health check, published last month, found 111 trusts failing one or more hygiene code standards.
Grim television images of dirty wards have already caused immense harm to the reputation of the Maidstone trust and to the broader NHS.
Has financial turnaround been achieved at the expense of patient safety? Are patients dying because of privatisation, or declining standards of basic cleanliness? Or is there something at the heart of the target-setting and performance-management culture that makes such crises inevitable?
James Lee, the chair of the Maidstone and Tunbridge Wells NHS Trust who resigned in response to the scandal, claims he was 'hung out to dry' by the Department of Health. He has been openly critical of the NHS being run 'on the basis of command-and-control'.
Jonathan Paine, a non-executive director of the trust, echoes his views. 'Patient care was supposed to be the top priority,' he says, 'but in reality external pressure meant that it had to be balanced against achieving government targets and financial balance.'
Lee's letter to Johnson notes that the trust had been 'struggling with a state pretty close to bankruptcy'.
A predictable reflex response from ministers has been to strengthen the mechanisms by which trust management can be called to account. Before the Maidstone and Tunbridge Wells story broke, Alan Johnson and junior minister Lord Darzi were already calling for quarterly reports on infection control and cleanliness from clinical directors and matrons, and for a legal burden on chief executives to report MRSA outbreaks (antibiotic-resistant strains of Staphylococcus aureus) and C. difficile to the Health Protection Agency – placing the duty on a named individual rather than on the organisation as a whole.
Johnson also announced that Ofcare, the new health and social care regulatory body, would be given far-reaching powers to inspect and issue warnings, impose fines, halt new admissions and even cancel a health services provider's registration entirely. The threat of potential corporate manslaughter charges hangs heavy in the air.
Department of Health reliance on inspection, performance management and fear of punishment has been accompanied by high-profile political interventions. In September, at the Labour Party conference, Prime Minister Gordon Brown pledged a 'deep clean' of all NHS hospitals. Shadow health secretary Andrew Lansley meanwhile advocated a 'search and destroy' attack on 'superbugs'. New uniform requirements, including the disappearance of hospital doctors' traditional white coats, take effect from the beginning of 2008. Darzi has called for the prior screening of all planned hospital admissions. And, although Brown has carefully avoided passing a parcel of blame to NHS management in general, he has gone out of his way to emphasise the role of doctors and nurses – and, specifically, matrons – in improving hospital hygiene.
Ah, matrons. John Reid reinvented the role when he was health secretary, yet the title still seems anachronistic. When Brown recently announced an increase to 5,000 in the number of hospital matrons, he stressed their role as the NHS's shock troops in getting private cleaning contractors to perform.
'Matrons will have the power to order additional cleaning and send out a message,' he said. 'Meet the highest standards of cleanliness or lose your contract.'
With many cleaning firms seemingly secure on long-term PFI contracts, and under fire for their employment practices, Brown's speech played well within the Labour Party. But the subtext of his rhetoric was: back to basics. Back to a world in which cleanliness is next to godliness, discipline and professionalism hold sway, visiting times are tightly regulated… and matron is in charge.
If only thorough scrubbing were enough to keep hospital-acquired infections at bay. But a normal person sheds an entire layer of surface skin every day or two. MRSA is spread by skin particles of carriers (more than 10% of us carry staphylococci on our skin) drifting into the air and settling on surfaces – including hospital bedding and pillows – where they await contact with vulnerable patients. The true key to controlling the spread of infection is not cleaning but isolation.
One statistic seized upon by the 'back to basics' lobby is an apparently remarkable absence of MRSA and C. difficile infections in British military operational hospitals. How can it be possible to run a hospital in the demanding and sometimes squalid environment of Afghanistan or Iraq, they ask, and yet keep wounded service personnel free from such infections? Surely the answer must lie in the army maintaining traditional standards of cleanliness that have been allowed to lapse elsewhere?
The basis of the military hospitals' success is, in fact, rather more prosaic. The population they serve does not generally include the older and infirm patients most vulnerable to infections within the NHS. The armed forces' care model for battle wounds essentially aims to stabilise patients and have them flown to the UK within 24 hours, headed mainly for large NHS-linked facilities in the Birmingham area. Most operational hospitals retain, most of the time, a large number of empty beds: their demand profile is unpredictable. And where, as in Afghanistan, facilities are also made available to the local population, there is no prevalence of MRSA or C.difficile among elderly people that might seed the spread of infections.
There is, however, perhaps another reason: clarity of objectives. The Ministry of Defence fully understands, from generations of experience, that keeping military hospitals working is crucial to the ability to wage war. And, just as in Lord Kitchener's day, military campaigns are more likely to be sabotaged by gastroenteritis than battle injury. Media reports focus on fatalities, but for every battle casualty an operational hospital is likely to see some five or ten patients with medical conditions. In 2002, an outbreak of severe infectious disease in one Afghanistan air base almost closed the hospital. No hospital, no war. For the forces, infection control is mission critical.
NHS boards, however, are expected to hit a far broader range of targets. The 2007/08 operating framework spells out four national targets that health economies are expected to prioritise. They can be summarised as:
- progress towards an 18-week maximum wait. By March 2008, 85% of care pathways within hospitals and 90% of care pathways outside hospitals are to be completed within 18 weeks
- reduction in rates of MRSA and other healthcare- associated infections. A headline national target of a 50% reduction in MRSA bacteraemias, with some hospitals pursuing more challenging reductions. MRSA is viewed, for this purpose, as a marker for a broader range of infections.
- reductions in health inequalities and progress in promoting health and wellbeing; and
- financial health.
The DoH has recently hinted that the list will remain broadly intact for 2008/09. In addition, most organisations face lists of locally agreed or imposed targets; while behind the seemingly bland 'financial health' requirement lies a whole spectrum of cash-releasing savings, efficiency gains, activity levels and the day-to-day business of keeping income and expenditure in balance.
It's small wonder that boards find it hard to prioritise. But there might well also be a deeper incompatibility between targets. The proportion of hospital trusts with bed occupancy running at 90% or higher has risen from 13% five years ago to 23%. A Royal College of Nursing survey estimates average bed occupancy to be 97%. Crucially, some doctors identify a causal link between the NHS's quest for increased efficiency in the form of higher bed occupancy levels and more intensive use of all hospital assets, and the spread of infection.
A significant number of consultant microbiologists support 14 recommendations for infection control proposed by Norman Simmons of the Guy's & St Thomas' NHS Foundation Trust. They include:
- hospitals being redesigned with enough single rooms to care for the majority of patients, and certainly all surgical patients
- restrictions on patient and staff movements, with medical and surgical patients staying in one ward or room from admission to discharge; and
- a reversion to 1970s' standards of laundry handling in particular the 'barrier principle' of entirely separating soiled and clean operations, dropped in the 1980s as too restrictive for competitive tendering.
As Simmons observes, if these were applied, government would find them expensive and managers would find them restrictive.
Saving lives, the DoH's own guidance on reducing infection, is severely practical and highly technical in comparison. Couched in the language of service improvement, it identifies 'high impact interventions' and clinical best practice for specific risk areas. The jury is still out on whether more drastic (and capital-intensive) action might be needed.
However, the business case for improving hygiene is unanswerable. In 2000, the National Audit Office estimated the cost of a bloodstream infection to be around £6,200. According to the DoH, the cost of a healthcare-associated infection is now typically between £4,000 and £10,000. Guy's & St Thomas' Trust has more than halved its MRSA bacteraemia rates since 2003, and is estimated to have saved around £1.4m as a direct consequence.
These calculations, and a useful tool for assessing the impact of infections on hospital productivity and potential savings from reducing infections, have been published by the DoH's MRSA and Cleaner Hospitals team. Going further faster (2006) estimates that a trust reducing its MRSA infections by 60% between 2004/05 and 2007/08 should by now be saving some £5.6m a year across all health care acquired infections. And that is before any litigation costs and possible catastrophic harm to reputation.
In plain financial terms, it's entirely possible to envisage improved infection control as a major component of a hospital's cost improvement programme. Yet it's also easy to see why, up to now, there has been a temptation for trust boards to sideline infection control as a technical issue, something to be left to the clinicians.
It's a temptation familiar to older NHS finance directors from the days when financial management could safely be left to the accountants.
Perhaps the repercussions of recent events in Kent will include NHS boards finally appreciating their full accountability for infection control – and the consequences of it going badly wrong.
Noel Plumridge is a former NHS finance director and the author of CIPFA's Payment by Results
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